PIC Heart Talk 2013and EP ConOctober 24 – 26, 2013

Can cardiac imaging improve patient outcome?

Richard Underwood

Professor of Cardiac ImagingImperial College London

Royal Brompton & Harefield Hospitals

Roles of imaging in CAD

• Diagnosis

• Coronary anatomy & function

• Myocardial anatomy & function

• Valve anatomy & function

• Objective assessment of symptoms

• Disease severity & burden

• Acute & chronic risk assessment

• Myocardial viability, stunning & hibernation

• Guiding revascularisation

• Monitoring therapy

Subspecialty Cardiac Imaging

• Echocardiography– Rest– Stress– Specialist (e.g. trans-oesophageal)

• Radionuclide imaging– Myocardial perfusion scintigraphy– Radionuclide ventriculography

• Magnetic resonance imaging

• X-ray computed tomography– Coronary calcium imaging– Coronary angiography

Cardiac Imaging 2011

MPS¹ PET perfn² sEcho² MR perfn¹ Coronary CT¹

0

500

1000

1500

2000

2500

3000

Test

s per

mill

ion

¹ECNC survey²Personal communications

How might imaging influence outcome?

• Avoiding diagnostic false negatives of less sensitive investigations

• Avoiding complications of invasive investigation

• Identifying patients with high but reversible risk

• Preventing intervention if no reversible risk

• Achieving similar outcome without intervention

• Achieving similar outcome at reduced cost

Myocardial perfusion scintigraphy

LVEF 74%

Prognostic value of MPS

• asymptomatic volunteers

• asymptomatic patients withabnormal sECG

• investigation of suspected CAD

• known CAD with stable angina

• after infarction

• after stabilisation of UA

• after revascularisation

• before non-cardiac surgery MPS normal MPS abnormal

0.7%

6.7%

Annual hard event rate

Underwood SR, et al. EJNM 2004; 31; 261-9129 studies , 20963 patients, mean follow-up 28m

Beliefs concerning PCI

Ann Intern Med 2010; 153: 307-13

Studies of ischaemia guided management

• A• BARI-2D• COURAGE• DEFER• ERASE• FAME• GRACE• INSPIRE• OASIS• etc

ACS No ACS0%

20%

40%

60%

80%

100%

84%

42%

85%

52%

MPS Normal care

Pati

en

ts a

dm

itte

d

Death or MI

Stroke Bleed Angina0%

5%

10%

15%

20%

Cath facilities No cath facilities

Relevant outcome studies

Study Topic Design

FAME FFR vs CAG guided PCI  Randomised

DEFER PCI vs MT  Randomised

Al Housni Ischaemia & PCI response, stable CAD  Observational

Hachamovitch

MT vs revasc, stable CAD  Observational

COURAGE OMT vs PCI, stable CAD  Randomised

INSPIRE MT vs revasc, after MI  Randomised

STICH MT vs CABG, impaired LV function  Randomised

PARR2 FDG PET vs standard care, impaired LV function  Randomised

EMPIRE Cost effectiveness of diagnosis  Controlled

END Cost effectiveness of diagnosis  Observational

Pijls NHJ et al. JACC 2010; 56: 177-84

FFR guided PCI, FAME 1Surv

ival fr

om

death

or

MI

• 1005 patients

• Multi-vessel disease undergoing PCI

• Randomised to CAG alone or FFR

P = 0.02

Fearon WF, et al. Circ 2010; 122: 2545-50

FFR guided PCI, FAME 2

De Bruyne B. NEJM 2012; 367: 991-10011220 patients, SCAD, FFR <0.8

Death, MI, urgent revasc Death

Stenting insignificant lesions

Pijls NHJ et al. JACC 2007; 49: 2105-11325 patients, elective PCI for intermediate stenosis

5 y

ear

card

iac

death

or

MI

DEFER study

Function v anatomy for symptoms

Al-Housni MB, et al. JNC 2009; 16: 869-77

123 patients, elective PCI

Procedure blinded to MPS

sECG baseline + 6 months

SDS 0

SDS 1-6

SDS >6

Hachamovitch R et al, 2011 doi: 10.1093/eurheartj.ehq50013555 patients, mean f/u 8.7yr, subset with <10% scar

Benefit of revasc vs medical therapy

% myocardium ischaemic

HR

earl

y r

evasc

vs

medic

al

PCI in stable angina

years

Free from death or MINEJM 2007; 356: 1503-16

Quality of LifeNEJM 2008; 359: 677-87

months

Shaw LJ, et al. Circulation 2008; 117:1283-91314 of 2287 patients, stable angina randomised to OMT or

PCI

Events and ischaemia

Events rates by ischaemia reduction

Baseline ischaemia

>10%

Events and ischaemia reduction

Shaw LJ, et al. Circulation 2008; 117:1283-91314 of 2287 patients, stable angina randomised to OMT or

PCI

Management after High Risk MI

• 205 patients, stable after MI

• Stress MPS defect >20%

• Reversible MPS defect >10%

• LVEF >35%

• Randomised to medical Rx or revascularisation

Mahmarian J, et al. INSPIRE trial JACC 2006; 48: 2458-67

Management after High Risk MI

Mahmarian J, et al. INSPIRE trial JACC 2006; 48: 2458-67

STICH trial

Bonow RO, et al. NEJM 2011; 364: 1617-25

HR 0.64 (95% CI 0.48-0.86)P = 0.003 unadjustedP = 0.21 risk adjusted

• 1212 patients with IHD & LVEF <35%

• Randomised to medical Rx or CABG

• 5 year follow-up

• 601 patients underwent viability assessment in non-random fashion

STICH limitations

• Nonrandomised selection of patients for imaging (601 of 1212)

• 72% of imaging referrals after randomisation

• MPS definition of viability: > 11/17 segments with uptake >50%

• Echo definition of viability: > 5/16 segments with abnormal resting function but contractile reserve to dobutamine

Hibernation and outcome

PARR2 study

• 430 patients, suspected CAD, LVEF <35%

• Randomised to FDG imaging or standard care

• Primary outcome cardiac death, MI or admission at 1 yearS

urv

ival fr

ee o

f 1

° outc

om

e

Beanlands RSG et al. JACC 2007; 50: 2002-12

P = 0.15

Perfusion viability mismatch

Beanlands RSG et al. JACC 2007; 50: 2002-12

Revascularisation or workup recommendation if “significant viability”

Hibernation and outcome

PARR2 study

• 430 patients, suspected CAD, LVEF <35%

• Randomised to FDG imaging or standard care

• Primary outcome cardiac death, MI or admission at 1 yearS

urv

ival fr

ee o

f 1

° outc

om

e

Beanlands RSG et al. JACC 2007; 50: 2002-12

P = 0.15

P = 0.019

Post hoc analysis

• 156 patients in PET arm who adhered to PET recommendation

Revasc benefit with extensive hibernation

D'Egidio G . . . Beanlands RGS JACCCI 2009; 2: 1060-8

Death, MI, admission

Cardiac death

>7% hibernationbenefit from revascularisation

PARR2 sub-study

182 patients randomised to PET arm

IHD and LVEF <35%

Hibernation and outcome

Abraham A . . . Beanlands RSG. JNM 2010; 51: 567-74

Ottawa-FIVE sub-study of PARR2

111 patients with:

1 Ready access to FDG

2 Expertise in FDG imaging

3 Integration between imaging,

4 Heart failure and

5 Revascularisation teams

Su

rviv

al fr

ee o

f 1

° outc

om

e

Two year costs (CAD absent)

Strategy 1 2 3 4 Scint Non-scint£0

£200

£400

£600

£800

£1,000

£1,200

£1,400

£1,600

£1,800

Management

Diagnosis

EMPIRE study. Eur Heart J 1999; 20: 157-66

P < 0.0001

P < 0.05P < 0.001

Rapid Access Chest Pain Clinic

• 1522 patients referred Dec 97 to Apr 2000 (630/yr)

• clinical management decisions by SpR with consultant supervision

Male % Female %

Ex-ECG 100 100

MPI 8 5

Angiogram 31 23

Normal angiogram 16 56

Wong Y et al. Heart 2001; 85: 149-152

Conclusion

Randomised controlled trials• Assessment of coronary function improves outcome in PCI

• Ischaemia reduction assessed by MPS improves outcome

• Conservative management after high risk MI identified by MPS has the same outcome as intervention

• FDG PET improves outcome in severe LV dysfunction in an expert centre

Controlled studies• MPS achieves equal diagnostic outcome at lower cost

Observational studies• MPS identifies patients who will benefit symptomatically from

PCI

• Patients with >10% myocardial ischaemia have improved outcome with revascularisation

Imaging & Cardiology

a natural partnership